Healthcare Provider Details

I. General information

NPI: 1518094846
Provider Name (Legal Business Name): JEREMY THAYER LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 SCRABBLETOWN RD
NORTH KINGSTOWN RI
02852-2001
US

IV. Provider business mailing address

452 GARDINER RD
WEST KINGSTON RI
02892-1068
US

V. Phone/Fax

Practice location:
  • Phone: 401-829-3355
  • Fax: 401-667-2733
Mailing address:
  • Phone: 401-829-3355
  • Fax: 401-667-2733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCSW00983
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW01934
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: